DATA PAGE POLICY NUMBER OWNER(S) MARY SMITH AND JOHN SMITH POLICY DATE SEPTEMBER 1, 2017 LIVES INSURED AND SCHEDULE OF BENEFITS INITIAL ANNUAL PREMIUM/PAYMENT MATURITY OR EXPIRY DATE $450.00 Life LIFE INSURED(S): MARY SMITH AND JOHN SMITH INSURANCE AGE: 43 RATE CLASS: NON-SMOKER LIFE INSURANCE Solution 10 Joint First Death Non-participating $500,000 Sum Insured Conversion Privilege September 1, 2049 $500,000 Total sum insured payable on the death of the first to die of the life insured(s) Included in this policy are pages with the following codes: GP-NP-1, SOL-3, CONV-3, JFD-2. Issued by the Company, September 1, 2017 DATA PAGE
SCHEDULE OF PREMIUMS POLICY The premiums shown in this schedule of premiums are for all coverages and include the policy administration fee. BEGINNING ANNUAL PREMIUM MONTHLY PRE-AUTHORIZED DEBIT PREMIUM September 1, 2017 September 1, 2027 September 1, 2037 September 1, 2047 September 1, 2057 September 1, 2074 $450.00 $2,800.00 $8,765.00 $29,005.00 $61,320.00 $0.00 $40.50 $252.00 $788.85 $2,610.45 $5,518.80 $0.00 SP
GENERAL PROVISIONS GP1 Definitions The following are definitions for some of the key terms used throughout this policy. Terms are also defined in other sections of this policy. Attained Insurance Age at any time is the Insurance Age increased by the number of policy years that have elapsed since the effective date of each Coverage. Company means The Empire Life Insurance Company. Coverage means any Life Insurance, Critical Illness Insurance, or Additional Benefit shown on the most recent Data Page. Death Benefit is any money that becomes payable under the terms of the contract if a Life Insured dies. Insurance Age for each Coverage is as shown on the most recent Data Page. It is based on the age of the Life or Lives Insured provided in the application and is subject to any modifications due to underwriting ratings. Life Insured means the individual whose life is insured as shown on the most recent Data Page. Life or Lives Insured means each individual Life Insured or all Life Insureds. Owner means the person or person(s) who own the contract and all of the rights, options and privileges associated with it. An Owner may also be a Life Insured. If the contract is owned by more than one person, they will be joint owners with right of survivorship, except in Québec. In Québec, joint owners who wish to obtain the same legal effect as the right of survivorship must each appoint the other Owner as his or her subrogated policyholder. Premium(s) means the amount payable for each Coverage and the policy administration fee. Proceeds means any money payable by the Company under the terms of the contract. Sum Insured means the insured amount for a Coverage, which is shown on the most recent Data Page. GP2 The Contract The contract includes the terms set out in this policy, in the original application for the contract, in any subsequent applications for a change to or reinstatement of the contract, and in any endorsements, all of which constitute the entire agreement between the Company and the Owner. The Owner and the Company may mutually agree to change a provision of the contract, subject to all applicable laws. In addition, the Company can waive a contract provision or change a contract provision if it does not lessen the Owner s rights or increase the Owner s obligations under the contract. Any change or waiver of a contract provision must be in writing and signed by an authorized officer of the Company to be valid. The contract will be governed and administered in accordance with the laws of the province or territory of Canada in which the Owner signs the application for this policy. When joint Owners sign the application for this policy in different locations, the province or territory of Canada where the first Owner signs will determine the laws that govern the contract. Other than in Québec, the contract will take effect only if: 1) the initial premium has been paid; and 2) the insurability of the Life or Lives Insured has not changed between the completion of the application for this policy and the delivery of this policy; and 3) the policy has been delivered to the Owner, an agent or assignee of the Owner, or the beneficiary. In Québec, the contract will take effect only if: 1) the initial premium has been paid; and 2) the insurability of the Life or Lives Insured has not changed between the completion of the application for the contract and the date the application is approved without modification by the Company. GP-NP-1-EN-1016
GENERAL PROVISIONS GP3 Incontestability If an Owner or Life Insured misrepresents or fails to disclose in the original application for the contract, or in any subsequent application to change or reinstate the contract that requires evidence of insurability, a fact that is material to the contract, the Company can void the contract. If an Owner or Life Insured misrepresents or fails to disclose in any subsequent application to change the contract that requires evidence of insurability, a fact that is material to the contract change applied for, the Company can void the contract but only in relation to the Coverage(s) affected by the contract change. The Company cannot void the contract or a Coverage affected by the contract change as described above after the contract or Coverage has been in force for a period of two years, unless one of the following applies: 1) the non-disclosure or misrepresentation constitutes fraud; or 2) the Coverage is a Waiver of Premium Benefit; or 3) the Coverage is a Critical Illness Coverage and a claim arises from symptoms or medical problems that commenced before the end of the two year period and lead to a Diagnosis or surgery, in which case, there is no time limit for voiding the contract or Coverage. The two-year period is measured from the later of the effective date of: 1) the contract; or 2) the Coverage affected by the contract change; or 3) the last reinstatement of the contract. Without limiting when misrepresentation or non-disclosure constitutes fraud, if the total premium charged for the contract is based, in whole or in part, on a declaration made on the application for this policy or any subsequent application for policy change or reinstatement as to the non-use of tobacco or tobacco products by the Life or Lives Insured and the declaration is false, the declaration will be deemed to be fraud and the contract will be void. Misstatement of age or sex will not be considered misrepresentation for the purpose of the contract. GP4 Currency Payments made to or by the Company will be in Canadian currency. GP5 Premiums The Schedule of Premiums page shows the total premium due for the contract and future adjustments in premiums for Coverages that have guaranteed premium rates on renewal. Premiums are payable in advance. Premiums may be paid on a monthly Pre-Authorized Debit basis or any other basis that is agreed to by the Company. No premiums will be due or payable after the contract terminates or becomes paid-up in accordance with the terms and conditions of a Paid-Up Option or Paid-Up Privilege, if applicable. The acceptance of any premium made in respect of any Coverage after the termination of that Coverage in accordance with its terms will not impose any liability on the Company and the premium will be refunded to the Owner. Other than as expressly provided in these General Provisions, premiums are not refundable, in whole or in part. GP6 Rescission Rights The Owner has 10 days after receiving the contract to change his or her mind about buying it. This is called a Rescission Right. If the Owner submits a request to rescind the contract, the Company will refund the initial premium to the Owner. GP7 Grace Period While the contract is in force, any premium, or any part of a premium that is not paid on or before the due date will constitute a premium in default. A grace period of 31 days after the due date of a premium will be allowed for payment of the premium in default during which time the contract will remain in force. If a Life Insured dies at any time during the grace period, an amount equal to any premium in default will be deducted from the Proceeds payable on the death of the Life Insured. GP-NP-1-EN-1016
GENERAL PROVISIONS If the contract includes Critical Illness Coverage for a Life Insured and the Life Insured is diagnosed with a Critical Illness during the grace period, an amount equal to any premium in default will be deducted from the Proceeds payable as a result of the Critical Illness. If a premium in default remains unpaid at the end of the grace period, and the contract includes a Coverage that earns Cash Values and there is Cash Value available, an automatic premium loan as described in CV5 Automatic Premium Loans will be applied. If the Company applies a premium loan as described above, it may change the premium payment frequency from monthly to annual. If the premium in default remains unpaid after the above steps have been taken, this policy will lapse and cease to be in force effective the due date of the premium in default. If this policy lapses, no Proceeds will be payable or privileges enforceable except if specified in a provision of this policy and then only to the extent and in accordance with the terms of the provision. GP8 Reinstatement If the contract lapses for non-payment as described in GP7 Grace Period, the Owner can apply to reinstate the contract within two years of the date it lapsed and ceased to be in force by: 1) paying to the Company all overdue premiums and any other Indebtedness owed to the Company at the time of application for reinstatement, plus interest; and 2) submitting evidence of the good health and other evidence of the insurability for the Life or Lives Insured, satisfactory to the Company. The reinstatement will be effective on the later of: 1) the date the Company receives all overdue premiums and other indebtedness; and 2) the date the Company determines that the submitted evidence of good health and insurability is satisfactory. GP9 Policy Years and Policy Anniversaries If the contract takes effect, the effective date of any Coverage applied for on the original application for the contract is the Policy Date shown on the Data Page. Policy years will be measured from that date. Each succeeding anniversary of the Policy Date will constitute a policy anniversary for those Coverage(s). The effective date for any Coverage applied for after the Policy Date shown on the Data Page is the date indicated by the Company in writing. Each succeeding anniversary of the effective date of those Coverage(s) will constitute a policy anniversary for those Coverage(s). GP10 Indebtedness "Indebtedness means all indebtedness owed to the Company under this policy at any time and will consist of the total of: 1) amounts loaned by the Company on the security of this policy; plus 2) interest on 1); less 3) the amount of any repayment of 1) or 2). The interest rate charged on Indebtedness will be set by the Company from time to time. Interest payable on Indebtedness will be compounded annually. Indebtedness will be a first charge against the contract in favour of the Company and in priority to the claim of any beneficiary, assignee or other person making a claim, and will be deducted from the Proceeds. Repayment, in whole or in part, of Indebtedness may be made to the Company at any time. GP11 Suicide If a Life Insured commits suicide, while sane or insane, within two years of the later of the effective date of: 1) the contract; 2) a Coverage for that Life Insured; or 3) the last policy change requiring evidence of insurability; or GP-NP-1-EN-1016
GENERAL PROVISIONS 4) the last reinstatement, the only amounts payable by the Company will be the Cash Value, determined at the date of death in accordance with the Cash Value Provisions, if the contract includes a Coverage that earns Cash Values and Cash Value is available. GP12 Payment of Proceeds Before making payment of any Proceeds, the Company will require: 1) sufficient proof of the right of the claimant to receive a payment; 2) satisfactory proof of age for the Life or Lives Insured; 3) for a Death Benefit, satisfactory evidence of the death and the cause of death of a Life Insured; 4) any other information the Company may reasonably require to establish the validity of the claim. On making payment of any Proceeds that become payable under the terms of the contract, a valid discharge of all liability under the contract for such Proceeds will also be required. Every action or proceeding against an insurer for the recovery of insurance money payable under the contract is absolutely barred unless commenced within the time set out in the Insurance Act (for British Columbia, Alberta and Manitoba), the Limitations Act, 2002 (for Ontario), or other applicable legislation (for all other provinces and territories). GP13 Settlement Options Proceeds payable under the terms of the contract will be paid by cheque, unless the person entitled to the Proceeds wants to use them to purchase an annuity or another settlement option available at the time the Proceeds are payable. Details of the options and the conditions under which they are available will be provided by the Company on request. GP14 Age and Gender If the age or gender of a Life Insured for any Coverage is misstated in the application for the Coverage, the Proceeds payable for that Coverage will be adjusted to the amount that would have been provided on the basis of the correct age or gender by the premium actually paid in respect of that Coverage. If, on the basis of the correct age, the Coverage would not have been available for that Life Insured, that Coverage will be void and cancelled and all premiums paid for that Coverage will be refunded to the Owner. GP15 Beneficiary for Death Benefit The Owner can designate one or more person(s) to receive the Death Benefit payable with respect to each Life Insured. Each designated person is called a beneficiary. The Owner can change or revoke the beneficiary designation, as permitted by applicable legislation, by a written declaration signed by the Owner and submitted to the Company. If the designation is irrevocable, it cannot be changed or revoked and certain privileges cannot be exercised without the irrevocable beneficiary s written consent. The Company assumes no responsibility for the validity or effect of any beneficiary designation. In the event of a common disaster, if the Company cannot determine the first to die of the Life Insured or the beneficiary, the beneficiary will be deemed to have died first. The Owner can designate primary and contingent beneficiaries. If a primary beneficiary dies before the Life Insured, that primary beneficiary s share will be divided equally among the remaining primary beneficiaries who survive the Life Insured. Any contingent beneficiary will become a beneficiary only if all of the primary beneficiary(ies) have died before the Life Insured, unless otherwise indicated by the Owner. If no beneficiary is designated or no designated beneficiary survives the Life Insured, the beneficiary will be the Owner, unless the Owner is the deceased Life Insured, in which case the beneficiary will be the estate of the Owner. GP16 Control of Policy Subject to the provisions of the law governing the contract and to the rights of any beneficiary, the Owner may: 1) exercise all the rights, options and privileges granted by the contract or permitted by the Company; and/or 2) assign the contract. The Owner can designate a contingent Owner or a subrogated policyholder (for Québec only) for the contract. If the Owner dies and the contract remains in force because the Owner is not the sole Life Insured, the contingent Owner or subrogated policyholder will have all the rights, options and privileges of the Owner. If no contingent Owner or subrogated policyholder has been named, all rights, options and privileges of the Owner will be transferred to the Life or Lives Insured GP-NP-1-EN-1016
GENERAL PROVISIONS under this policy. GP17 Assignment The Company will not be bound by any assignment of the contract, unless it is in writing and filed with the Company. The Company assumes no responsibility for the validity or effect of any assignment of the contract. GP18 Termination of a Coverage A Coverage will terminate, 1) on the date payment of the Sum Insured for that Coverage is made; or 2) when the Company receives a written request from the Owner to terminate the Coverage; or 3) at the expiry date for the Coverage as shown on the most recent Data Page; or 4) when the contract terminates, whichever occurs first. GP19 Termination of the Contract The contract will terminate: 1) if all Coverages have been terminated; or 2) for non-payment of premiums as described in GP7, Grace Period; or 3) at any time Indebtedness exceeds the Cash Value; or 4) when the Company receives a written request from the Owner to cancel the contract, whichever occurs first. GP-NP-1-EN-1016
SOLUTION SERIES LIFE INSURANCE PROVISIONS These provisions will apply to only those Coverages identified as Solution 10, Solution 20, Solution 100 or Solution ART (referred to below as a Coverage ) shown on the most recent Data Page. If there is a conflict between a Solution Series Life Insurance Provision and a General Provision, the Solution Series Life Insurance Provision will apply. SS1 Sum Insured The Sum Insured for a Coverage on a Life or Lives Insured is as shown on the most recent Data Page. The Sum Insured is guaranteed not to change while the Coverage is in force, unless the Owner submits a written request to decrease it. SS2 Deferred Non-Smoker Provision If the Insurance Age of a Life Insured is 17 or less and, if within 60 days of the policy anniversary nearest that Life Insured s 18th birthday, the Owner submits to the Company satisfactory proof that the Life Insured has not used any tobacco or nicotine products within the previous 12 months, the Company will reduce the portion of the policy s premium applicable to that Life Insured effective from that policy anniversary. The amount of the reduction in the total annual premium will be determined based on the Company s rules in effect at the Policy Date shown on the Data Page. SS3 Paid-Up Benefit Premiums are payable until the policy anniversary nearest the Life or Lives Insured s Attained Insurance Age 100. If all premiums due until the policy anniversary nearest the Life or Lives Insured s Attained Insurance Age 100 are paid, the Coverage becomes paid-up, which means no more premiums will be due or payable. The Coverage will remain in effect until it terminates in accordance with GP18 Termination of a Coverage. SS4 Death Benefit If the Life Insured dies, the Company will pay, as part of the Proceeds of the contract, the Sum Insured for a Life Insurance Coverage on that Life Insured provided the Life Insurance Coverage is in force on the date of death. SOL-3-EN-1016
LIFE INSURANCE CONVERSION PRIVILEGE PROVISIONS C1 Conversion Privilege If a Coverage has a conversion privilege (as indicated on the most recent Data Page), the Owner may convert all or part of the Coverage on a Life Insured to a new life insurance coverage, without any further evidence of the insurability of that Life Insured, provided the conversion privilege has not expired. The conversion privilege expiry date for a Coverage is as shown on the most recent Data Page. The Owner selects the new coverage, subject to the following conditions: 1) the new coverage must be a level premium permanent whole life insurance plan then being offered by the Company; and 2) the Sum Insured for the new coverage cannot be greater than the Sum Insured specified on the most recent Data Page for the Coverage being converted. The new coverage will become effective and the Coverage or portion of the Coverage being converted will terminate at the time of the conversion. The premium for the new coverage will be determined by the Company at the time of the conversion, using: 1) the Life Insured s Attained Insurance Age; 2) the Life Insured s rate class (smoker or non-smoker); and 3) the risk class for the Coverage being converted, unless the risk class of the Coverage being converted is not available on the new coverage, in which case a standard risk class will apply. The new coverage may include a Waiver of Premium Benefit if, at the time of the conversion: The new coverage may include an Accidental Death and Dismemberment Benefit if, at the time of the conversion, the Life Insured has an Accidental Death and Dismemberment Benefit on the Coverage being converted. The Sum Insured for the Accidental Death and Dismemberment Benefit cannot be greater than the Sum Insured for the Accidental Death and Dismemberment Benefit specified on the most recent Data Page for the Coverage being converted, 1) the Life Insured has a Waiver of Premium Benefit on the Coverage being converted; and 2) the Life Insured is not totally disabled, as defined in the Waiver of Premium Provisions, at the time of conversion. The Owner may exercise this conversion privilege by submitting to the Company, an application for the new coverage, a request for termination of the Coverage or the portion of the Coverage to be converted and the initial premium due for the new coverage. C2 Special Conversion If a Coverage includes a Waiver of Premium Benefit for the Life Insured and has a conversion privilege (as indicated on the most recent Data Page) and: 1) the Life Insured is totally disabled prior to the policy anniversary nearest the Life Insured s sixtieth birthday; and 2) the Life Insured remains continuously disabled until the date specified on the most recent Data Page for the expiry of the conversion privilege on that Coverage, then the Owner may convert the Coverage to a non-participating level premium permanent whole life insurance plan then being offered by the Company, without any further evidence of the insurability of the Life Insured, provided the conversion privilege has not expired. The Coverage being converted will terminate on the date the new coverage becomes effective. The new coverage resulting from this special conversion will: 1) include a Waiver of Premium Benefit; and 2) have the same Sum Insured as the Coverage being converted; and 3) become effective on the conversion privilege expiry date for the Coverage being converted as shown on the Data Page. CONV-3-EN-1016
LIFE INSURANCE CONVERSION PRIVILEGE PROVISIONS The Owner may exercise this special conversion privilege by submitting an application for the new coverage and a request for the termination of the Coverage to be converted to the Company within 90 days prior to the conversion privilege expiry date for the Coverage being converted as shown on the Data Page. CONV-3-EN-1016
JOINT FIRST DEATH PROVISIONS These provisions will apply to only those Coverages identified as Joint First Death Coverage on the most recent Data Page. JFD1 Death Benefit On the death of the first of the Lives Insured, the Company will pay as part of the proceeds of this policy, the Sum Insured for the Joint First Death Insurance Coverage, provided the Coverage is in force. JFD2 Joint Conversion Privilege If the insurance Coverage includes a Conversion Privilege and/or a Special Conversion Privilege, such privileges will apply subject to the Life Insurance Conversion Privilege Provisions, provided the new insurance will be on a Joint First Death basis for the Lives Insured. JFD3 Survivor Continuing Coverage Period The insurance Coverage will automatically continue on the life of the survivor of the Lives Insured for a period of 90 days following the date of death of the first of the Lives Insured or until the expiry date of the Coverage for this Joint First Death insurance as indicated on the Data Page, if earlier. If, at the end of this Survivor Continuing Coverage Period, the Owner has not applied to the Head Office of the Company for continuing benefits under Provision JFD4, the insurance Coverage will automatically terminate and there will be no further premiums due or benefits payable for this Coverage. JFD4 Survivor Conversion Privilege During the Survivor Continuing Coverage Period the Owner may purchase new insurance Coverage on the life of the survivor, without further evidence of insurability, subject to the following conditions: 2) the Sum Insured for the new insurance Coverage cannot be greater than the Sum Insured specified on the 1) the Owner must select the new insurance Coverage from any level premium permanent whole life insurance plan then being offered by the Company; and most recent Data Page for the Joint First Death Coverage. If this policy contains a Waiver of Premium provision and the survivor is the Life Insured for that Waiver of Premium provision, the new insurance Coverage may include a Waiver of Premium provision provided that the survivor is not totally disabled at the time of conversion. The new insurance Coverage will become effective as of the date of death of the first of the Lives Insured and all premiums will be due and payable to the Company from that date. The premium for the new insurance Coverage will be determined by the Company as of the date of death of the first of the Lives Insured, using: 1) the survivor s attained Insurance Age; 2) the survivor s original rate class (smoker or non-smoker); and 3) the risk class that applied to the Joint First Death Coverage. If the risk class is not available on the new insurance, a standard risk class will apply. The Owner may exercise this survivor conversion privilege by submitting a written application for survivor conversion and the initial premium due to the Head Office of the Company at any time within the Survivor Continuing Coverage Period. JFD5 Special Survivor Conversion Privilege Notwithstanding the above, if: 1) this policy includes a Waiver of Premium Provision; and 2) the survivor is the Life Insured for that provision; and 3) the survivor is totally disabled at the date of death of the first of the Lives Insured, JFD-2-ENG-1016
JOINT FIRST DEATH PROVISIONS the insurance Coverage provided under this Joint First Death provision will continue on the life of the survivor until the expiry date of the Waiver of Premium benefit. For the purpose of this provision, the expiry date is defined as the first to occur of: 1) the date on which the survivor ceases to be totally disabled as defined in the Waiver of Premium provision; or 2) the expiry date of the Waiver of Premium provision. At the expiry date indicated above, this Coverage may be converted to any non-participating level premium permanent whole life insurance plan then being offered by the Company. The Coverage resulting from this special conversion will: 1) include a benefit providing for the waiver of premium payments, provided that the survivor is still eligible for such benefit; and 2) not be greater than the Sum Insured for the Joint First Death Coverage on the survivor as specified on the most recent Data Page; and 3) become effective at the expiry date indicated above. The premium for the new insurance Coverage will be determined by the Company at the expiry date indicated above, based on: 1) the survivor s attained Insurance Age; 2) the survivor s original rate class (smoker or non-smoker); and 3) the risk class that applied to the Joint First Death Coverage. If the risk class is not available on the new insurance, a standard risk class will apply. JFD-2-ENG-1016